| NPI | 1134931330 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 95034980) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: AZ 249781) |
| Enumeration Date | 2025-01-23 |
| Last Update Date | 2026-08-04 |